Asthma is a common disease characterized by variable airways obstruction and inflammation. The disease varies in severity from mild intermittent to very severe forms, causes significant morbidity, greatly affects the quality of life of asthmatics and their families and has significant direct and indirect costs to patients and society. In the last twenty years, extensive investigation of the pathogenetic mechanisms of asthma has led to a better understanding of the disease and to a more cognitive approach to its therapies. Although controlled studies show that most asthmatic patients can achieve asthma control and lead normal lives with moderate doses of medication (1-2), surveys show that a substantial number of patients still face symptoms and limitations, probably due to inadequate management (3). This is a matter of concern for both the medical community and health authorities, as control of asthma can and should be achieved in the majority of patients.

  In order to combat the problem of asthma, global guidelines have been published to promote standardized methods for the diagnosis and treatment of the disease (4). These guidelines have been disseminated widely and there are reports showing that doctors are aware of the recommendations (5) and that the quality of life of mild asthmatics is similar to that of the general population (6). However, studies also show that although doctors accept the guidelines, their patients are not always treated accordingly (5, 7) and a fairly recent multinational survey shows that indeed the life of asthma patients is affected by the disease to a great extend (3).

According to the GINA guidelines (4), the Goals of Long-term Management are to:

• Achieve and maintain control of symptoms
• Prevent asthma episodes or attacks
• Maintain normal pulmonary function
• Maintain normal activity levels, including exercise
• Avoid adverse effects from asthma medications
• Prevent irreversible airflow limitation
• Prevent asthma mortality Also according to the GINA guidelines there are specific steps for successful management and these are to:
• Assess severity
• Regular follow-up
• Educate patient (risk factor avoidance, aims of treatment, role of specific drugs)
• Know the patient and define his/her needs
• Provide individualized written instructions (for long-term management and exacerbations)

There are four major factors that determine the success rate of any therapeutic intervention: the disease which may be mild or severe, the medications which may be effective or not, the patient who may be compliant or not and the doctor who may have the proper training and attitude to successfully assess and treat or not. Furthermore, in asthma, as in all chronic diseases, patient education is of seminal importance and so is a good patient-doctor relationship.

Disease severity in asthma is classified in four stages and as severity progresses, more medication classes and higher doses are used. It is important to correctly assess severity and initial assessment includes history and spirometry while follow-up includes PEF monitoring, asthma control questions or questionnaires and repeat spirometry.

Questions that may help doctors define the severity include:

• How often do you experience symptoms?
• How often do you wake up with asthma?
• Can you do all the things you want?
• How often do you need your relief medication?
• Do you experience breathlessness when walking, going uphill or running?

Considering medication, there are 3 issues that affect compliance and success of therapy. These are whether the medications are effective, whether they have side-effects and whether they are affordable or too costly for the patient. Asthma medications are effective and have few side-effects. Studies in the last 10 years have shown that combining more than one class of drugs and in particular inhaled steroids and short and long-acting beta agonists but also other medication classes provides better asthma control (1,4,8). Furthermore, it is important to provide simple dosing regimens which will help compliance and affordable drugs. Patient compliance is determined by the patient’s personality, level of education, cultural beliefs and co-morbidities, in particular depression and psychiatric disorders which may negatively affect asthma control. Education of the patient regarding the disease is very important, helps compliance and dramatically reduces the number of exacerbations (9).

It should contain information on:

• What is asthma ?
• What is the purpose of controller medication, how and when is it taken, how quickly it acts ?
• What is the purpose of reliever medication, how and when is it taken, how quickly it acts ?
• Proper inhalation techniques ?
• Avoidance of triggering factors
• Early recognition and treatment of exacerbations

Finally, successful asthma management requires that the doctors treating the patient are up to date and follow guidelines.

It is also extremely important that doctors treat the patient:

• Taking into account his way of life, his needs and his preferences
• Discussing options and arriving at common decisions

A patient-centered approach is heavily recommended in the literature and may ensure successful asthma outcome.

création: décembre 2006